Millcreek Behavioral Health / Habilitation Center, Inc.

• (1) Licensing Complaint is true.
  • Child involved admitted to allegations of acting inappropriately.
  • Corrective Action: Underage aggressor placed on safety plan requiring strict supervision.
• (2) Licensing Complaint is true.
  • Staff were not providing the appropriate level of supervision with multiple children in the bathroom unsupervised by staff.
  • Corrective Action: Safety plan initiated for children involved in report to be followed by direct care staff.
• (3) Licensing Complaint is true.
  • Standards Reviewed: 102.3a,f,g; 907.2,3. Personnel Record reviewed of alleged offender. Agency determined that staff violated agency policy.
  • Corrective Action: Staff was terminated by agency.
• (4) Licensing Complaint outcome unknown.
  • Reviewed 1 children’s record, no deficiencies cited. No licensing determination was provided at this visit. A finding will be provided at a later date.
• (5) Licensing Complaint unfounded.
  • Reviewed personnel file of alleged offender, no deficiencies cited.
  • Corrective Action: Staff was retrained on Abuse Prohibition (8/20/19).
• (6) Licensing Complaint unfounded.
  • Reviewed personnel records of 2 staff with no deficiencies cited. There was no supporting evidence found during investigation to support allegations.
  • Corrective Action: Staff was retrained on TCI and personal appearance policy (8/1/19).
• (7) Licensing Complaint unfounded.
  • Reviewed personnel record with no deficiencies cited. No evidence found during investigation to support allegations.
  • Corrective Action: Staff was retrained on Zero Tolerance Policy for Abuse and TCI (7/31/19).
• (8) Licensing Complaint unfounded.
  • Reviewed personnel record of 1 staff member. No supporting evidence found during investigation to support allegations.
  • Corrective Action: Staff was retrained on Abuse Prohibition and TCI (7/18/19).
• (9) Licensing Complaint unfounded.
  • Reviewed personnel record for 1 staff member. No supporting evidence found during investigation to support allegations.
  • Corrective Action: Staff was retrained on Crisis Co-Regulation and Zero Tolerance Policy (8/5/19).
• (10) Licensing Complaint unfounded.
  • Standard Reviewed: 103.2. Reviewed 3 personnel records: CMCRs needed on staff. No supporting evidence found during investigation to support allegations.
  • Corrective Action: Staff was retrained on Professional Dynamic Risk Assessment and Camera Policy (7/25/19).
• (11) Licensing Complaint unfounded.
  • No supporting evidence found on allegations.
  • Corrective Action: Children involved have been placed on close monitoring by staff.

• Viewed Kangaroo Hall and all areas used by children. Storage rooms in staff office area have fire hazard concerns with clothing and paperwork around pipes.

(1) Licensing Complaint is true.

• Standards Reviewed: 405.5; 907.2. Personnel Record reviewed with no deficiencies.
• Corrective Action: Staff was terminated (6/6/19).

(2) Licensing Complaint is true.

• Standards Reviewed: 404.4c,d; 905.4c,d. Personnel Record reviewed with no deficiencies.
• Corrective Action: Agency provided retraining of staff (7/18/19).

(3) Licensing Complaint outcome not stated.

• Standards Reviewed: 102.3h; 907.2. Personnel Records reviewed with no deficiencies.
• Corrective Action: Retraining of staff completed on abuse, neglect, and exploitation.

(4) Licensing Complaint is true on underage aggressor.

• Corrective Action: Safety plan was initiated for involved child for strict supervision.

(5) Licensing Complaint is true on underage aggressor.

• Corrective Action: Safety plan initiated for involved child for strict supervision. New van procedures put in place when transporting children.

(6) Licensing Complaint unfounded.

• No supporting evidence was found during investigation to support allegations. Standards Reviewed: 405.5; 907.2. Personnel Record reviewed with no deficiencies.
• Corrective Action: Therapeutic Crisis Intervention retraining provided to staff.

(7) Licensing Complaint is true.

• Standards Reviewed: 405.5; 907.2.
• Corrective Action: Staff was terminated by agency.

(8) Licensing Complaint is true.

• Standards Reviewed: 404.4c,d; 905.4c,d. Personnel Record reviewed with no deficiencies cited.
• Corrective Action: Retraining of staff completed on Abuse Prohibition (6/27/19).

(9) Licensing Complaint is true.

• Standards Reviewed: 405.5; 907.2. Personnel Record reviewed with no deficiencies.
• Corrective Action: Staff was terminated (6/16/19).

• Viewed Eagle Hall, Dragon Tree, Oak Creek, Willow Creek, and the Boy’s Ranch and grounds used by children.
• Regs out of compliance –
  • 911.6, 911.15 – Dragon Tree; Electrical outlet in bedroom 4 is bent with sharp metal edges needing replacement. Corrected 7/30/19.
  • 409.6, 408.1 – Willow Creek; Locks needed on backyard storage units, broken chair with sharp edges needs disposal and exposed nails on fence by the driveway needs repair or disposal. Corrected 7/30/19.
  • 409.6 – Oak Creek; Freezer in kitchen has molded appearance and needs either cleaning or disposal. Corrected 7/30/19.
  • 409.6 – Boy’s Ranch; Bathroom in bedroom 6 has strong urine stench that needs attention. May require deep cleanse or floor repair to get out the smell.

• Licensing Complaint is true. Staff left involved child on Kangaroo Hall alone. Standards Reviewed: 907.2, 3.
• Corrective Action: Agency has placed staff on Administrative Leave (7/15/19). Agency will provide in-service training to staff on making sure that patients are counted coming and going from area to area.

• Licensing Complaint is true. Standards Reviewed: 907.2, 405.5.
• Corrective Action: Staff member terminated.

• Licensing Complaint unfounded. No evidence found to support allegations.